HEDIS Tip Sheet 2021 Medicaid Women's Health Measures - Blue Cross and Blue Shield of Illinois
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HEDIS Tip Sheet 2021
®
Medicaid Women’s Health Measures
The National Committee for Quality Assurance (NCQA) has developed Healthcare Effectiveness Data and Information
Set (HEDIS) measures as a tool for performance improvement. We collect HEDIS data from our providers to measure and
improve the quality of care our members receive. The NCQA recommends tracking the following HEDIS measures for our
Blue Cross Community Health PlansSM (BCCHPSM) members.
How to improve HEDIS scores
HEDIS Measures On the following page are measure definitions,
BCS: Breast Cancer Screening documentation requirements and helpful tips you may
choose to follow to improve HEDIS scores. Compliance
CCS: Cervical Cancer Screening
with HEDIS measures reduces the need for you to send
CHL: Chlamydia Screening in Women additional medical records later for review. You may also
PPC: Prenatal and Postpartum Care refer to the HEDIS Quick Reference Guide for BCCHP,
can be found in the Clinical Resources/HEDIS section of
our Provider website at bcbsil.com/provider.
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an independent Licensee of the Blue Cross and Blue Shield Association 240435.0121
Breast Cancer Screening (BCS) Cervical Cancer Screening (CCS)
Measure definition for BCS: Women 50 to 74 years of Measure definition for CCS: Women 21 to 64 years of
age who had a mammogram to screen for breast cancer. age who were screened for cervical cancer using any of the
following criteria:
Documentation Requirements • Women 21 to 64 years of age who had cervical cytology
• Document screenings in the medical record. The performed within the last 3 years
medical record must indicate the specific date and • Women 30 to 64 years of age who had cervical high-risk
result of the screening human papillomavirus (hrHPV) testing performed within
• Document a bilateral mastectomy in the medical record the last 5 years
• This measure evaluates primary screening. Do not • Women 30 to 64 years of age who had cervical cytology/
count biopsies, breast ultrasounds, MRIs or high-risk human papillomavirus (hrHPV) co-testing
tomosynthesis (3D mammography) within the last 5 years
Helpful Tips Documentation Requirements
• D
iscuss the importance of early detection and • A note indicating the date when the cervical cytology
encourage testing was performed and the result or finding
• D
iscuss possible fears the patient may have about • A note indicating the date when the hrHPV test was
mammograms and inform them that currently performed and the result or finding
available testing methods are less uncomfortable • Generic documentation of “HPV test” can be counted as
and require less radiation evidence of hrHPV test
• H
ave a list of mammogram facilities available to • Document in the medical record if the patient has had a
share with the patient hysterectomy with no residual cervix and include terms
like total, complete or radical hysterectomy
• Do not count biopsies because they are diagnostic and
therapeutic only and are not valid for primary cervical
cancer screening
Helpful Tips
• C
omplete Pap tests during regularly-scheduled well
woman visits, sick visits, urine pregnancy tests,
urinary tract infection (UTI) and chlamydia/ sexually
transmitted infection screenings
• R
equest to have results of Pap tests sent to you if
done at OB/GYN visits
Prenatal and Postpartum Care (PPC)
Measure definition for PPC: Deliveries of live births on or
between October 8 of the year prior to the measurement
year and October 7 of the measurement year. For these
women, the measure assesses the following facets of
prenatal and postpartum care:
• Timeliness of Prenatal Care: Deliveries that received a
prenatal care visit in the first trimester, on or before the
enrollment start date or within 42 days of enrollment in
the organization
• Postpartum Care: Deliveries that had a postpartum visit
on or between 7 and 84 days after delivery
Documentation Requirements
• Prenatal care visit to an OB/GYN or other prenatal care
practitioner, or primary care physician (PCP). For visits to Documentation in the medical record must include a note
a PCP, a diagnosis of pregnancy must be present. indicating the date when a postpartum visit occurred and
Documentation in the medical record must include a one of the following:
note indicating the date when the prenatal care visit
• Pelvic exam
occurred, and evidence of one of the following:
• Evaluation of weight, BP, breasts and abdomen.
• Basic physical obstetrical exam that includes
Notation of “breastfeeding” is acceptable for the
auscultation for fetal heart tone, or pelvic exam with
“evaluation of breasts” component
obstetric observations, or measurement of fundus
height (a standardized prenatal flow sheet may be used) • Notation of postpartum care (PP), PP check, PP care,
six-week check, or pre-printed “Postpartum Care” form
• Obstetric panel
in which information was documented during the visit
• Ultrasound of pregnant uterus
• Perineal or cesarean incision/wound check
• Pregnancy-related diagnosis code
• Screening for depression, anxiety, tobacco use,
• TORCH antibody panel (Toxoplasma, Rubella, substance use disorder or preexisting mental
Cytomegalovirus, and Herpes simplex testing) health disorders
• Rubella antibody test/titer with an Rh incompatibility • Glucose screening for women with gestational diabetes
(ABO/Rh) blood typing (e.g., a prenatal visit with rubella
• Documentation of any of the following: infant care or
and ABO, a prenatal visit with rubella and Rh, or a
breastfeeding, resumption of intercourse, birth spacing
prenatal visit with rubella and ABO/Rh)
or family planning, sleep/fatigue, resumption of physical
• Documented last menstrual period (LMP) or estimated activity and attainment of healthy weight
date of delivery (EDD) with either a completed obstetric
Addition of Telephone Visits, E-visits and
history or prenatal risk assessment and
Virtual Check-ins
counseling/education
Postpartum Care: Had a postpartum visit to an OB/GYN NCQA has made changes to its HEDIS measures.
practitioner or midwife, family practitioner or other PCP on Telephone visits, e-visits and virtual check-ins have been
or between 7 and 84 days after delivery. added as eligible methods for use in reporting both rates.
Helpful Tips
• Schedule prenatal care visits starting in the first trimester or within 42 days of enrollment
• Have a direct referral process to obstetrician-gynecologist (OB/GYN) in place
• Refer BCCHP patients to our Special Beginnings Program
• S
chedule your patient for a postpartum visit within 7 to 84 days from delivery (please note that staple removal
following a cesarean section does not count as a postpartum visit for HEDIS)
• Educate the patient on the leading causes of postpartum complications and mortality
Continued on next page.
Chlamydia Screening in Women (CHL) Helpful Tips
• P
erform chlamydia screening every year on every
Measure definition for CHL: Women 16 to 24 years of age
16 to 24-year-old female identified as being
who were identified as sexually active and who had at least
sexually active
one test for chlamydia during the measurement year.
• Inform patient that chlamydia screening can be
Documentation Requirements performed through a urine test. Offer this as an
option for patients
• Date test was performed and the result
• P
lace chlamydia swab next to Pap test or pregnancy
detection materials
Clinical Practice Guidelines
can be found in the
Clinical Resources/Clinical
Practice Guidelines section of
our Provider website at
bcbsil.com/provider.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association,
an association of independent Blue Cross and Blue Shield Plans.
HEDIS is a registered trademark of the NCQA
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care
providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact
that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more
details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.You can also read
